10 Sports Injuries Not to Miss. Jessica Juntunen, MD Primary Care Sports Medicine

Transcription

1 10 Sports Injuries Not to Miss Jessica Juntunen, MD Primary Care Sports Medicine

2 I have no financial interests or relationships to disclose in regards to this presentation

3 12 yo RHD male baseball pitcher presents with R elbow pain for one month. Began after pitching back-to-back games at a tournament. Doesn t recall feeling a pop or any visible bruising. Localized medially. Greatest pain with late cocking phase of pitch. Seems to improve with rest, but returns every time he tries to return to pitching.

4 Little league elbow apophysitis of the medial epicondyle growth plate due to repeated valgus stress, most commonly associated with overhead throwing associated with increase # pitches and decrease in rest period between seasons 9-12 yo

5 adults tend to injure UCL, while greatest force is localized to UCL attachment in adolescents most will have normal XR COMPARISON VIEWS MRI may help to confirm diagnosis or evaluate for any ligamentous injury

6 treatment = REST for 3 months* USA Baseball Medical and Safety Advisory Committee pitch counts 8-10 yo: yo: yo: yo: 105 for pitchers, 3mo rest from all overhead throwing physical therapy eventual, gradual return to throwing with interval throwing program

7 14yo M RHD pitcher presents with R shoulder pain x 6 wk. Pain with pitching - worst in cocking and deceleration phases. Tender lateral shoulder/proximal humerus. Improves with rest.

8 Little League shoulder Apophysitis/epiphysiolysis of proximal humerus Adolescent males > females Pain in both late cocking (rotational torque) and deceleration (distraction) phase of pitch Pitch # greatest risk factor

9 May report decreased pitch velocity On exam, may have: Tenderness at level of physis Pain in ER GIRD XR to evaluate for widening MRI may be useful to confirm dx and r/o other pathology Treatment: 3mo rest, PT, gradual throwing program

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11 22 yo F college basketball player presents with R wrist pain following FOOSH injury onto R hand. Pain along radial side of hand and wrist. Some swelling of thenar eminence.

12 Scaphoid Fracture Most commonly fractured carpal bone Usually due to fall with wrist extended and axial load (FOOSH injury) Snuffbox tenderness on exam major blood supply is dorsal carpal brach of radial artery and 80% of scaphoid is supplied via retrograde flow risk of AVN and non-union

13 Initial imaging with XR If negative XR, but high clinical suspicion, may treat empirically with spica cast/brace and f/u for repeat XR or proceed with advance imaging MRI first-line advanced imaging CT or bone scan are other options Proximal and displaced fractures higher risk of non-union surgical referral usually if displaced >1mm When treated conservatively, 3-6 mo for healing

14 20 yo M soccer player presents with L ankle pain. Foot was caught up under another player during a tackle. Felt like ankle was twisted. Immediately unable to bear weight. Worst pain is anterior and lateral. Significant edema and ecchymosis of ankle.

15 High Ankle Sprain (syndesmosis injury) Syndesmosis maintains integrity between tibial and fibula Can be a/w fractures of distal fibula, 5th metatarsal, talus Important to recognize, as missed diagnosis may lead to significant, early DJD of ankle

16 Presents like severe sprain - swelling, bruising Anterolateral pain tenderness proximally, over syndesmosis Unable to weight bear Provocative tests: squeeze test external rotation fibular drawer

17 Initial XR to include AP, lateral, mortise views consider WB, external rotation stress, XR of proximal fibula, and contralateral views if suspicious XR may show decreased tibiofibular overlap increased medial clear space increased tibiofibular clear space MRI, CT

18 Conservative treatment, NWB in tall boot followed by progression to WB in boot and PT variable recovery/healing time; much longer than normal ankle sprain only if no diastasis or instability

19 33yo M flag football player presents with R foot pain. Injury occurred during a tackle when another player fell onto heel of his plantar flexed foot. He cannot bear weight and reports diffuse pain through fore foot. There is medial plantar ecchymosis noted.

20 Lis Franc Injuries Lis franc ligament spans articulation from the medial cuneiform to base of 2nd metatarsal lis franc complex consists of TMT, inter metatarsal, and inter tarsal articulations spectrum of injury: sprains > fracture-dislocation of TMT joint Axial load through hyper plantar flexed foot Missed injury = chronic pain, deformity

21 presentation: pain and tenderness TMT joint, NWB, swelling, medial plantar bruising pain with pronation and abduction* +instability test (if +, plantar ligaments are torn, and surgery may be indicated) If unstable, XR may show widened interval between 1st and 2nd ray medial base of 2nd MT does not line up with medial side of middle cuneiform dorsal displacement of 1st or 2nd MT

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23 Advanced imaging: MRI or CT* non-op/stable - cast/boot immobilization 8+ weeks unstable - operative - ORIF, arthrodesis

24 17 yo F runner presents with L hip pain. Gradual worsening over last 3-4 months. No injury. Runs miles per week. Pain begins earlier and earlier into run and now has some discomfort walking.

25 Femoral neck stress fracture Rare*, but may be catastrophic if missed average diagnostic delay of 14 weeks insidious onset of groin/hip pain with impact and sometimes at extremes of ROM

26 Compression v tension side compression more common and more stable XR is usually normal MRI is imaging of choice Treatment non-op: NWB, crutches compression side, fatigue line <50% neck width operative: ORIF w/percutaneous screw tension side or compression side >50%

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28 32 yo M sprinter presents with bilateral lower leg pain. R began 2 months ago and L began over last 2 weeks. Worsening and occurring sooner into practice. No neurovascular symptoms. No pain with strength or ROM testing at knee and ankle. Pain bilaterally when tuning fork is placed to anterior tibia.

29 Tibial shaft stress fracture runners, military recruits insidious onset pain usually well localized to stress reaction/fracture site XR first; MRI most sensitive

30 Treatment: activity restriction and protected WB avoid NSAIDs bone stim? Other locations to consider stress injuries: distal fibula, metatarsals (specifically 5th MT), femoral shaft

31 15 yo M football lineman presents with low back pain, worsening over the last 6mo. No specific injury. Hurts with extension. No radicular symptoms.

32 Spondylolysis Stress injury of pars Due to repeated low back hyperextension Gymnasts, cheerleaders, dancers, swimmers/divers, weight lifting, football linemen On exam, pain with back extension Begin with XR may visualize sclerosis or defect on lateral or oblique views ( scotty dog )

33 If suspect spondy, move on to advanced imaging MRI Treatment is rest, eventually followed by PT and gradual RTP opinions differ on time and bracing 3-6 months If left untreated, may cause continued pain and progress to bilateral defect and spondylolithesis

34 16 yo F soccer player collides with another player during a hard tackle. Impact isn t seen, but she stumbles a bit getting to her feet. When she comes to sideline, she complains of mild vertigo, but says she is otherwise fine and wants to continue to play.

35 Concussion > 50% are not reported A prior history of concussion(s) negatively impacts an athletes likeliness to report symptoms Important to do a quick assessment if any suspicion A concussed athlete should not return to play same game Many assessment tools (e.g. SCAT, Impact) key is consistency Importance of physical and mental rest

36 15 yo male football player present with R groin pain. Began suddenly, following a pop while running sprints at practice. Pain in anterior groin. Unable to continue practice. Cannot perform straight leg raise. Tenderness over iliopsoas.

37 Lesser trochanter avulsion Avulsion of distal iliopsoas tendon Usually feel a pop and cannot perform SLR Look for avulsed fragment off lesser trochanter on XR Treatment (unless significant displacement): activity restriction, protected WB, no progression until visible healing on XR Also consider AIIS avulsion (rectus femurs)

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39 Benjamin HJ, Briner WW. Little League Elbow. Clin J Sport Med 2005; 15: Brooks S, Cicuttini FM, Lim S, et al. Cost effectiveness of adding magnetic resonance imaging to the usual management of suspected scaphoid fractures. British Journal of Sports Medicine 2005; 39: Clough TM. Femoral neck stress fracture: the importance of clinical suspicion and early review. British Journal of Sports Medicine 2002;36: Masci PL, Malara F, et al. Use of the one-legged hyperextension test and magnetic resonance imaging in the diagnosis or active spondylolysis. British Journal of Sports Medicine 2006; 40: Pediatric Spondylolithesis and Spondylolysis. Orthobullets (online). Updated 6/26/17. Register-Mihalik JK, et al. Relationship Between Concussion History and Concussion Knowledge, Attitudes, and Disclosure Behavior in High School Athletes. Clin J Sport Med 2017; 27: Scaphoid Fracture. Orthobullets (online). Updated 9/18/18. Selhorst M, Fischer A, MacDonald J. Prevalence or Spondylolysis in Symptomatic Adolescent Athletes. Clin Journal of Sports Med 2017; volume publish ahead of print. Sman AD, Hiller CE, Rae K, et al. Diagnostic accuracy of clinical tests for ankle syndesmosis injury. Br J Sports Med 2015;49: